NJ’s Medicaid Watchdog Expands Audit and Exclusion Efforts

A recent report from the New Jersey Office of the State Comptroller indicates an expansion of the efforts of its Medicaid Fraud Division (MFD) to investigate fraud, waste and abuse in the New Jersey Medicaid Program. The report also highlights MFD’s expanded effort to exclude providers from the Medicaid Program.

In fiscal year 2016, the MFD recovered $112.6 million from various providers the MFD claimed were improperly paid by Medicaid. Audited providers included pharmacies, adult day care centers, home health care providers, and doctors. MFD’s recovery represents a nearly 30 percent increase compared to the $87.2 million recovered in 2015. The division also coordinates and oversees activities with those of the Recovery Audit Contractor, which helped to identify additional $13 million in alleged overpayments.

The MFD’s other activities include analyzing and investigating complaints/fraud tips, excluding providers and vetting of high-risk providers upon enrollment into the Medicaid Program. In 2016, the agency excluded 109 providers, which represents a nearly 27% increase in exclusion activity from the prior year. Similarly, last year the MFD analyzed the merits of nearly 2,000 fraud tips/complaints from various sources and opened investigations in 407 cases. In analyzing enrollment applications, the MFD analyzed and investigated 433 high-risk providers seeking enrollment and denied enrollment to 13 providers due to program integrity concerns. The MFD also conducts pre and post enrollment unannounced provider/supplier visits.

If you have questions about the New Jersey Medicaid Fraud Division, Medicaid enrollment, revalidation, exclusion or debarrment, or have other health law related questions, please contact our office.

Deniza Gertsberg, Esq. is an attorney representing healthcare providers in New York and New Jersey. This article is published for informational purposes only; it contains no legal advice whatsoever. Publication of this article does not create an attorney-client relationship. Please see our full disclaimer.

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